need to meet minimum patient volumes or revenues tied to the
Advanced APM. In 2018 the thresholds are 25 percent of payments
or 20 percent of patients must be attributed to the Advanced APM.
For the 2019 and 2020 performance years this increases to 50 percent of payments or 35 percent patient volume. In 2021 and later,
this increases to 75 percent of payments and 50 percent of patients
through the Advanced APM. Clinicians also need to be listed as
participants in the Advanced APM on one of three snapshot dates:
March 31, June 30, or August 31.

Potential downsides include shared financial risk based on Advanced APM performance, which in general will increase over
time, narrowing margins to demonstrate improvement, and the
increasing patient volume and payment thresholds needed to
achieve QP status noted above. Advanced APMs could potentially
become more selective towards their membership, with high-performing clinicians and practices becoming increasingly valued.

The New ACO Track 1+ Model and Expanded Enrollment in Ex-isting Advanced APMs

The Medicare Shared Savings Program ACO Track 1+ Model is
available for participation in 2018. CMS anticipates that a significant number of Track 1 Medicare ACOs will convert to the Track
1+ model, which qualifies as an Advanced APM. This will create
new opportunities for MIPS-eligible clinicians to become QPs
based on participation during the 2018 performance period.

Expanded enrollment is anticipated for other existing Advanced APM models. There will be additional enrollment opportunities in 2018 and future years for clinicians to join the
Next Generation ACO model and the Comprehensive Primary
Care Plus (CPC+) Model.

All-Payer Advanced APMs

All-Payer Combination Advanced APMs will be available starting
in the 2019 performance year. All-Payer Combination Option participation requires that clinicians participate in both a CMS-ap-proved Advanced APM and an Other Payer Advanced APM. These
range from Medicaid, Medicare Advantage, and CMS multi-payer
models to commercial/private payer Advanced APMs. Eligible
clinicians would still need to meet the relevant QPP or Partial QPP
thresholds under the All-Payer Combination Option on one of the
three snapshot dates: March 31, June 30, or August 31.

MACRA Strategies for 2018, Future Performance Years

Three high-level options will be considered.

Option One: Participate in an Advanced APM (if available).

As noted previously, eligible clinicians that achieve QP status areexcluded from MIPS payment adjustments and having their MIPSscore published on the Physician Compare website. They also re-ceive a five percent lump sum payment during the correspondingpayment year for the first six years of the QPP. Clinicians may alsobe eligible for shared savings. Advanced APMs may be the mostattractive option for many clinicians and practices, although theshared risk component needs to be taken into consideration. Inaddition, as noted previously APMs are under increasing pres-sure to perform and may become increasingly selective towardsmembership. An individual clinician’s or group’s ability to dem-onstrate high performance in the MIPS could be seen as an indi-cator of potential high performance in an Advanced APM.Option Two: Participate fully in the MIPS in 2018 and attemptto attain the highest possible MIPS score. Performance scoresare not expected to be at their highest level during the 2018 per-formance year since a high percentage of clinicians are new to theprogram. This creates an opportunity for better prepared practicesto obtain optimal MIPS performance scores. As noted in Figure 1on page 24, MIPS scores of 100 points in 2018 may generate posi-tive payment adjustments of approximately three percent in 2020.

The greatest challenge to attaining high MIPS scores is performance in the quality category. CMS anticipates that a high
percentage of clinicians will achieve the maximum scores for
the ACI and Improvement Activities categories. A significantly
lower percentage will achieve maximum scores in the quality
and cost performance categories

Quality also has the highest weighting of any category in 2018.
Many quality measures have elevated benchmarks that make
achieving optimal scores more challenging. In order to achieve a
high quality performance score, practices will need to establish
workflows that facilitate optimal scoring for each targeted quality
measure. This will require a detailed assessment of available measures including reporting mechanisms, benchmarks, population
requirements, potential denominator exclusions and exceptions,
and data capture methodologies. The data completeness requirement is 60 percent for this category, allowing for some flexibility
if programs were not in place on January 1, 2018. The data can be
collected retrospectively, but high performance is generally dependent upon prospective efforts to educate clinicians and staff on
best practices for addressing measure requirements and captur-ing/documenting needed data elements. It also requires the individual managing MIPS performance to be responsive to negative
trends; allowing them to perform root cause analysis and interventions when low performance is identified.

The ACI and Improvement Activities categories require a minimum period of 90 days of continuous engagement in 2018. The
Cost category performance period is a full calendar year, but there
is no reporting requirement. However, Cost performance is dependent upon risk-adjusted scores which are determined by demographic and clinical conditions. This places additional emphasis
on ICD-10-CM coding completeness and specificity. The complex
patient bonus is partially determined by HCC coding. Together
these factors should drive high-performing practices to increase or
maintain their levels of disease coding accuracy.

Full participation in the MIPS in 2018 is recommended when
Advanced APM options are not available or not felt to be a good fit
for the practice. Concentrated efforts to optimize performance in
MIPS represents the best option to prepare for performance in 2019.
As noted above, CMS anticipates that 74 percent of clinicians will
have MIPS scores of 70 points or higher in 2018. That suggests that
the MIPS performance threshold will be significantly higher than
75 points in 2019. Another consideration is that MIPS performance
scores will be published on the Physician Compare website. Low
scores may create challenges with patient recruitment and retention,